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    <title>Application to Uppsala International Summer Session 2010</title>
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        $text = "June 12 - August 20: Box 1972 SE-751 49 Uppsala, Sweden, tel: +46-18-102370, fax: +46-18-121218, mobile: +46-70-4375866";
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    <table>
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        <td>{fileupload photo}</td>
        <td style="text-align:right;"><img style="width: 132px; height: 120px;" src="{location}/images/uiss.jpg" id="UISS-logo" alt="Logo UISS" name="UISS-logo"></td>
      </tr>
    </table>
    <h1>Application to Uppsala International Summer Session 2010</h1>
    <h2>Participation</h2>
    <table>
    {dropdown sessions sessions choose I wish to attend the:} 
    {dropdown morning morning choose I wish to participate in the following morning course:} 
    {dropdown afternoon1 afternoon1 choose I wish to participate in the following afternoon course (June 20 - July 16):} 
    {dropdown afternoon2 afternoon2 choose I wish to participate in the following afternoon course (July 18 - August 13):}
    </table>
    <h2>Placement test</h2>
    <table>
      <tr>
        <td class="attend">
          My number of correct answers = {data correct_answers} in level {data level} of the placement test.
        </td>
      </tr>
    </table>
    <h2>Name and address</h2>
    <table>
      {dropdown title titles choose Title}</td>
      {fill-in family_name Family name}      {fill-in first_name First name}      {fill-in date_of_birth Date of birth}
      {fill-in street Street}
      {fill-in zip_code Zipcode}
      {fill-in city City}
      {dropdown country countries choose Country}
      {dropdown nationality nationalities choose Nationalities}
      {dropdown usstate usstates choose State}
      {fill-in e-mail E-mail}
      {fill-in telephone Telephone number}
      {fill-in fax Fax number}
      {fill-in profession Profession}
      {fill-in university University}
      {fill-in major_department Major department}
    </table>
    <h2>I wish to reside in a</h2>
    <table>
      {radioset accommodation SINGLE single room}
      {radioset accommodation DOUBLET doublet <span class="small">(a small unit of two single rooms with kitchenette and bathroom, limited availability)</span>}
      {radioset accommodation APPT apartment, single occupancy <sup>*</sup>}
      {radioset accommodation 4a apartment, shared with other student <sup>*</sup>}
      {radioset accommodation 4b apartment, shared with friend <sup>*</sup>}
      {radioset accommodation 4c apartment, shared with partner <sup>*</sup>}
      {radioset accommodation 5 apartment with non participant partner <sup>*</sup>} 
      {fill-in number_of_children Children}
      {radioset accommodation 6 I will arrange my own accommodation, reduction in cost 3.000 SEK per 4-week period}
      {checkbox car arrival with my car}
    </table>
    <h2>Special wishes</h2>
    <table>
      {checkbox special_tuition I wish to attend the program 'tuition only' 13.000 SEK per 4 weeks, 6.700 SEK per 2 weeks}
      {checkbox special_vegetarian I would like to request vegetarian meels}
      {radioset vegetarion nofish no fish} 
      {radioset vegetarion fish with fish}
    </table>
    <h2>Proficiency in languages</h2>
    <table>
      <tr><th>Language</th><th>Reading</th><th>Speaking</th><th>Writing</th></tr>
      {language english English}
      {language swedish Swedish}
      {language german German}
      {language_other language_1}
      {language_other language_2}
    </table>
    <h2>Activities</h2>
    <p class="attend">
      The following activities, excursions or lodging involve extra costs.
      Please mark the ones you would like:
    </p>
    <table>
      {checkbox activities_1 Finland trip, July 8 - July 12. Deposit 1.000 SEK. Total cost 2.400 SEK.}
      {checkbox activities_2 Lapland trip, July 16 - July 21. Deposit 1.500 SEK. Total cost 3.600 SEK.}
      {checkbox activities_3 Värmland trip, July 30 - August 1. Deposit 1.000 SEK. Total cost 2.300 SEK.}
      {checkbox activities_3_1 rafting}
      {checkbox activities_3_2 adventure experience}
      {checkbox activities_3_3 hiking}
      {checkbox activities_4 apartment, single occupancy or with non-participant partner: 4.000 SEK per 4 weeks, 2.400 SEK per 2 weeks}
      {checkbox activities_5 apartment, shared with participating friend, partner or other student: 1.500 SEK per person per 4 weeks}
      <tr>
        <td colspan="4">
          <div class="remark">
            The non-refundable deposit for the optional trips and the costs for
            the apartment should be paid together with the advance course
            payment of 5.000 SEK. The remaining costs should be paid with the
            final course fee payment.
          </div>
        </td>
      </tr>
    </table>
    <h2>How did you hear about the Uppsala program?</h2>
    <table>
      {checkbox heard_1 Have known about it for several years and have been waiting for the opportune time to apply}
      {fill-in heard_url Internet, website:}
      {fill-in heard_name Heard about it from friend, teacher, etc: name}
      {fill-in heard_poster_other Poster on campus or at}
      {fill-in heard_read Read about the program (newspaper etc)}
      {fill-in heard_requested Requested information from}
    </table>
    <h2>Disclaimer and agreement</h2>
    <table>
      <tr>
        <td>{checkbox disclaimer I understand that the UISS program arrangements, including the course offerings, may be subject to minor modifications}</td>
      </tr>
      <tr>
        <td>{checkbox agree_and_pay I have paid a non-refundable application fee of $50 or EUR 30 to complete my application}</td>
      </tr>
    </table>
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